Category: Health Policy

Nov
9

Medicare, drug prices, abortion and medical debt – Midterms’ impact on healthcare –

Posted by Joe Paduda on Wednesday, November 9th, 2022 | Comments

Here’s a quick-albeit-still-somewhat-up-in-in-the-air take on how the midterms may/will impact healthcare. Much depends on final results in several key elections (Senate in GA, NV, :

Medicare and Medicaid

Drug prices – Biden’s Inflation Reduction Act will reduce seniors’ drug prices; if the GOP takes control of the House (which appears likely) it may try to hold up/block/hinder Medicare drug price negotiation through oversight on how HHS implements the new policy.

If Dems hold onto the House (which is highly doubtful),  we can expect legislation that would expand Medicare and Medicaid.

South Dakotans voted to expand Medicaid; this is a big win for rural hospitals and the uninsured – 40,000+ South Dakotans will now have access to health care. For South Dakotans, the impact – healthier people and financially healthier hospitals = healthier economy.

Abortion rights

Ballot measures in 5 states addressed abortion rights with voters in California, Vermont, Michigan, and Kentucky (!) passing measures to protect women’s right to choose; as of early this morning no word on Montana.  Note there are nuances specific to each state; CA MI and VT’s votes enshrined a right to an abortion in their respective state Constitutions while KY defeated a measure that would have explicitly stated nothing in the state’s Constitution creates a right to abortion.

impact – while the votes in CA and VT were no surprise, MI was less certain and KY’s result is notable indeed; Kentucky joins Kansas as another relatively red state whose voters protected abortion rights.

These wins may well drive anti-abortion candidates and politicians to re-think their stance or risk voter backlash.

Investigations, oversight, and the like

If Republicans gain control in the House (likely) and/or Senate (maybe/maybe not) expect a raft of investigations into all manner of Medicare, Medicaid, COVID response, drug pricing and other issues real and imagined.

The biggest thing no one is talking about

Voters in Arizona overwhelmingly backed a measure intended to protect people from medical debt collections and collectors. 

From the Arizona Mirror:

Prop. 209 would reduce the maximum interest rates that could be collected from 10% to 3% annually. Currently, up to 25% of wages can be garnished by creditors, but Prop. 209 would limit that to just 10%. Courts would also be allowed to reduce the amounts being garnished in cases of extreme economic hardship, a power they don’t currently have.

I fully expect activists in other states to jump on this; it is hugely popular and desperately needed.

What does this mean for you?

Watch the updated results to see what happens with the House and Senate. That will drive what really happens…

 

Nov
3

Republicans planning to force Medicare cuts

Posted by Joe Paduda on Thursday, November 3rd, 2022 | Comments

House Republicans are planning to impose massive cuts to Medicare, raise Medicare’s eligibility age, and withhold payments to early retirees and retirees earning more than a certain limit.

News sources indicate the GOP will use the upcoming debt limit to try and force Medicare cuts, a reprise of earlier efforts supported by 175 House Republicans to slash Medicare spending. The effort is also gaining traction among Senate Republicans, with Senator Lindsey Graham planning to use the Republicans’ leverage in Congress to cut Social Security and Medicare.

Sen. Rick Scott’s 11 point plan goes a lot further; it would end Social Security and Medicare if Congress doesn’t take specific action to renew those programs every few years (see Scott responding to Fox News question at 1:09 of the video here.)

You may well recall that Scott was sued for Medicare fraud back when he ran Columbia/HCA. Columbia/HCA was ordered to pay the Feds $1.7 billion in fines and penalties.

What does this mean for you?

If you and/or your parents are on Medicare, this means a lot. 

 

Oct
12

How we measure “value” in healthcare is all wrong.

Posted by Joe Paduda on Wednesday, October 12th, 2022 | Comments

The most popular formula for calculating the “value” of healthcare is pretty simple…

If you want to get a bit deeper into details, there’s this…

It’s about the “quality” of the medical procedure (was it done right? was the patient re-admitted? was there a surgical error or infection), perhaps the appropriateness of that procedure, and the “patient experience” – measured…somehow.

Pretty much every formula, discussion, or description of the healthcare value equation is focused on “outcomes” defined as the result of a surgery or treatment (did the patient get better?) or avoidance of sickness or injury (did the patient stay “healthy”).

None – as in none – focus on what’s really important to you and me –

Did the healthcare we received maintain/improve our ability to function – to raise our kids, work, exercise, function in society, do things we like to/have to do.

Functionality is the only “value” metric that matters, yet pretty much no one in healthcare and no healthcare organization – except in workers’ comp – talks about functionality, measures their results based on functionality, reports member functionality, studies it or seeks to improve overall member functionality as a core goal (except for a few unique healthplans).

Further, employers, who pay hundreds of billions of dollars on healthcare insurance premiums don’t even think about the impact of that healthcare on employee functionality/productivity.

Why?

Procurement, CFOs, finance departments and management are constantly challenged to show a return on investment on any project, hire, new initiative, acquisition or investment.

But never when they are buying healthcare – which, after payroll, is the biggest single part of the budget for most service companies and a major cost for every type of employer – public, private, not-for-profit.

Nope, it’s the thickness of the provider directory, whether or not some health system is in that directory, perhaps some “quality” rating, plus the biggie – cost.

What does this mean for you?

We are buying healthcare all wrong.

Oct
11

The problem with primary care?

Posted by Joe Paduda on Tuesday, October 11th, 2022 | Comments

It doesn’t generate profits for the medical-industrial complex.

From a societal perspective primary care is wildly undervalued – and wildly under-appreciated – because primary care doesn’t make money for anyone, especially primary care providers.

Which makes no sense on every front but the profit one. If everyone had good primary care,

  • they’d be healthier,
  • their health risks would be identified early and a plan developed to address them,
  • they’d have a provider who treats them as a whole person, who understands that we are a bunch of tightly-interrelated organ systems that have to be considered as a whole, not as individual organs,
  • they’d understand non-physical issues can be just as impactful as physical ones,
  • there’d be a lot less need for specialists, and
  • healthcare costs would likely be a lot lower.

Healthier people don’t need as many medications, devices, treatments, injections, therapies, surgeries, rehab, inpatient beds or surgical centers as unhealthy people.

And that’s where the money is.

Kaiser Permanente has generally excellent primary care – yet it can’t/hasn’t been able to translate that excellence into a sustainable competitive advantage.

I believe that’s because KP – and pretty much everyone else – is thinking about the “value” of healthcare the wrong way.

Tomorrow – how we define value today – and why that is wrong.

Aug
15

I’m turning optimistic…

Posted by Joe Paduda on Monday, August 15th, 2022 | Comments

After too many months of doom-scrolling catastrophic weather events, rising inflation, ridiculously high medical costs, Russian fascism, social media wars over gender issues and elected officials that can’t seem to do anything but campaign for their next election, I’m starting to get just a little optimistic…

The economy…is doing pretty darn well. (Most of the below from Scott Galloway)

  • Employment has risen every month this year and we added more than 500,000 jobs in July
  • The unemployment rate is near a 50-year low.
  • Family spending – which accounts for 70% of the economy – has increased five of the last six months.
  • Two out of three companies in the S&P three companies have beaten Wall Street’s revenue estimates, and three in four have beaten earnings estimates.
  • According to one economist peoples’ fears are “completely at odds with the reality. I’ve never seen a disjunction between the data and the general vibe quite as large as I saw.”
  • yeah, inflation…but it was lower in July than June, and gas prices are down 20% from their high earlier this year…

Congress is actually getting a LOT done.

The just-passed Inflation Reduction Act will:

Oh, and the legislation also kept 13 million folks’ health insurance premiums affordable, which will keep more of us alive.

On the state level, it’s not just stupid waste-of-time caterwauling about gender issues… Colorado just passed bi-partisan legislation that “prevents hospitals or their collectors from initiating or pursuing debt collection from a patient if the hospital’s website was not in compliance with the Centers for Medicare and Medicaid Services (CMS)’ price transparency requirements at the time services were delivered”

Kudos to Colorado’s legislators for doing something Congress SHOULD HAVE DONE – put some damn sharp teeth in hospital price transparency legislation.

What does this mean for you?

Things are better than some would have you believe!

Aug
12

Health insurance saves lives

Posted by Joe Paduda on Friday, August 12th, 2022 | Comments

A just-released study shows people with health insurance are a little less likely to die than those without insurance. 

That is not surprising; preventive care, access to medications to control diabetes, hypertension, depression, cancer and the like, and early diagnosis of potentially life-threatening diseases are all going to keep people alive longer.

From the study:

The study approach taken by the research team bypassed concerns raised against previous non-experimental research on this topic.

The outreach intervention was a joint project designed primarily by the Treasury Department’s Office of Tax Analysis, funded by the Department of Health and Human Services (HHS), and implemented by the IRS.

What does this mean for you?

Health insurance saves lives.

For workers’ comp, the implications are clear – workers who have health insurance are likely to be healthier than those without – and therefore more likely to recover from occupational injuries or illnesses.

Aug
1

Just the facts, ma’am…

Posted by Joe Paduda on Monday, August 1st, 2022 | Comments

Today we’re doing a very quick recap of stuff we learned over the last couple of weeks…no opinion here (yeah that was really hard for me…)

Extra credit for identifying the man in the picture…

But first, for those of us perennially mad at ourselves because, well, we screw up and aren’t perfect, read this. Short take – perfectionism…

“…makes for a thin life, lived for what it isn’t rather than what it is. If you’re forever trying to make your life what you want it to be, you’re not really living the life you have.”

Drug prices

Make for great politics…even when all the caterwauling is wrong. The issue is what we – the consumer – pay is NOT what insurers, PBMs, and other payers pay.

That’s due to the “gross-to-net bubble”, a term popularized by the estimable Adam Fein Ph.D.

When rebates and discounts were factored in, brand-name drug prices declined—or grew slowly—in 2021.

So…you getting those rebate checks?

COVID’s origins

Remember the theory that COVID came from a Chinese lab? It is looking increasingly sketchy.

A comprehensive, detailed, and multi-factor analysis by scientists from four continents found

the emergence of SARS-CoV-2 occurred via the live wildlife trade in China, and show that the Huanan market was the epicenter of the COVID-19 pandemic.

The peer-reviewed research published in the journal Science covered molecular epidemiology and spatial and environmental analyses.

Investors and physician practices

Private equity investment in physician practices varies a lot by specialty and region. Quick takes…

  • about 5% of physicians were in private equity-acquired practices
  • The highest percentage was in D.C. (18.2%)
  • More than one in ten docs in AZ, CT, FL, MD, and FL were in PE-acquired practices

The researchers wrote…

“Because some private equity acquisitions consolidate physician practices into larger organizations, geographic concentration of private equity penetration may be associated with reduced physician competition, which could lead to increased prices, [emphasis added]

An interactive map and the research report are here.

Gun violence

Gun makers earned over 1 Billion (with a B) dollars from sales of military-style assault weapons over the last decade. A report to Congress found:

  • gun makers marketed to young men by claiming their weapons will put them “at the top of the testosterone food chain”…
  • the weapons were described as an “apex predator”
  • some ads for these weapons “mimic first-person shooter video games popular with children.”

source here

The AR-15 is the most common of these weapons…the NRA named it “American’s Rifle” back in 2016. (and here I always thought it was Davy Crockett’s flintlock rifle…)

(disclosure – I hunt and have several rifles – none are semi-auto like the AR-15)

Workers’ comp physician fee schedules

…are all over the place…Louise Esola at Business Insurance reported on a recent WCRI analysis that found:

About one-quarter of the fee schedule states established their rates for office visits near the Medicare level or below, while about the same number of states set their fees for major surgery at triple the Medicare rates or more in each state…

The study – authored by Olesya Fomenko and Te-Chun Liu and up to date as of this spring – is here. (sorry for misspelling of Dr Fomenko’s  name in  earlier version…darn spellcheck!)

Clearly politics trumps policy…unless someone can tell us why it makes sense for Florida to pay docs below Medicare, while paying hospitals many times Medicare… I’ll stick to politics, campaign contributions, lazy legislators and hand-cuffed or ineffective regulators as the main driver of work comp fee schedules. (oops opinion inserted into post…just can’t stop myself)

Happy August!

Jul
18

(Perhaps) unintended consequences of abortion bans

Posted by Joe Paduda on Monday, July 18th, 2022 | Comments

With all the attention paid to abortion these days, I thought it worthwhile to dig into the financial and health impact of abortion and childbirth.

First, the cost.

Women who give birth incur about $19,000 in additional healthcare costs compared to women who don’t.

And that’s for women covered by large employers’ health plans.

Second, medical debt.

Lower-income adults in the South and/or in states that have not expanded Medicaid are much more likely to have medical debt than the rest of us.

Third, coverage.

About 13 million of us will see their health insurance premiums jump in January unless Congress acts. The issue is subsidies for lower-income folks who get their insurance via the Exchanges will expire at the end of this year unless they are extended. So far, the chances for an extension don’t look promising.

Fourth, societal costs.

  • Almost half of the women receiving abortions have incomes below the poverty line.
  • Lives will be hugely impacted, as “the expansion of abortion access … reduced teen motherhood by 34% and teen marriage by 20%”
  • Women who are denied abortions are three times more likely to be unemployed than women who were able to receive one, according to a 2018 study.
  • Women who were not allowed to access abortion services had nearly a four times greater chance of living below the federal poverty line.
  • And…”research shows that in 2010 the public paid just under $13,000 on “prenatal care, labor and delivery, postpartum care and 12 months of infant care.” per birth.”

Connecting the dots.

States that have or are likely to ban abortion are:

  • unlikely to have expanded Medicaid,
  • have much more restrictions on Medicaid coverage so far fewer people qualify for Medicaid, and
  • therefore many more poor women who are forced to have children will have higher medical debt,
  • will not escape living in poverty, and their child will grow up poor.

What does this mean for you?

If one is going to force people to do things, one should understand and be responsible for the consequences.

Jul
11

Healthcare Sharing Ministries and the brutal reality of medical debt

Posted by Joe Paduda on Monday, July 11th, 2022 | Comments

Last week I posted on Health Care Sharing Ministries, noting I’d been reaching out to the PR firm that works with theAlliance of Health Care Sharing Ministries, the PR people put out a release touting their new accreditation standards.

As I noted last week the accreditation process/requirements don’t appear to require minimum cash reserves, specific expense ratios or meet other financial adequacy minimums and the accreditation board doesn’t include individuals with actuarial or financial credentials.

In English, this is a very big deal. Unlike real health insurers, HCSMs aren’t required to have enough cash to pay your medical bills. Also unlike health insurers, members don’t have any recourse if their “ministry” decides your care isn’t worthy of their support.

This comes on the heels of a recent study that found almost a third of all Americans have medical debt; in their efforts to pay off debt respondents made a number of sacrifices and suffered substantial financial consequences: (actual study and responses from KFF)

  • cutting back on household spending
  • more than four in ten say they or a household member have used up all or most of their savings
  • respondents reported skipping payment on other bills,
  • and delaying college or buying a home, or changing their housing situation, while
  • half of adults with health care debt say they have made what they feel to be a difficult sacrifice in order to pay down their debt
  • One in seven adults with health care debt say they have been denied care by a provider due to unpaid bills

Here’s the truly awful thing…the least fortunate among us are in the worst shape.

I get that some people have had good experiences with HCSMs. I also know others have not, and are now among those with crippling, life-changing medical debt.

What does this mean for you?

HCSMs are no silver bullet…rather they are a “send the check in and hope you are covered if you get hurt or sick” non-solution.

It’s a measure of just how dysfunctional our healthcare system is that HCSMs even exist.

Ed note – I’ve been holding off on this post for days, hoping to hear something from AHCSM. I’ve repeatedly asked the PR firm for more details; evidently the right folks haven’t been able to respond.

I first reached out to the PR contact on June 21, 2022…three weeks ago.

 

Jul
6

Healthcare Sharing Ministries – the latest

Posted by Joe Paduda on Wednesday, July 6th, 2022 | Comments

Healthcare costs are about to jump again, driven by exploding staffing expenses, continued healthcare provider consolidation, and the brilliant profiteering by some of the largest (mostly for-profit) healthcare systems.

So, what’s a family to do?

A few have turned to Healthcare Sharing Ministries, a thing that looks like health insurance but isn’t. HCSMs purport to “share” health care costs among members in what might best be described as a risk-pooling framework. Almost all claim to be “Christian”, they are largely unregulated (except as charities), don’t comply with insurance regulations or laws in most states, and most have requirements that members:

  • are in good health,
  • make a statement of Christian belief, attend church regularly, don’t use tobacco or have sex outside of marriage and
  • commit to taking care of their own health.

note there are ministries focused on other religious denominations.

So…sounds good right? cheaper healthcare is better…well, HCSMs also:

  • are not legally required to pay your medical bills,
  • require enrollees to do much of the groundwork to get bills paid (negotiate upfront with the provider, get all the paperwork and documentation, pay upfront then seek reimbursement)
  • medically underwrite – meaning they require disclosures of pre-existing conditions and can reject applicants for medical reasons,
  • can refuse coverage to anyone for any reason,
  • have limits on what they’ll pay for healthcare,
  • can’t guarantee healthcare providers will accept sharing ministry coverage, and
  • have appeals processes that aren’t subject to regulatory oversight.

Enrollment is a bit hard to nail down; the Alliance of Health Care Sharing Ministries claims 1.5 million enrollees although it doesn’t specify the year. Other reports indicate AHCSM reported membership was “over 1 million” in February of 2019. Other sources report membership closer to that 1 million figure.

HCSMs tend to be significantly cheaper than health insurance plans, making them increasingly attractive. However, most families that buy health insurance through the exchanges get major subsidies that significantly reduce their premiums.

There have been multiple reports of individuals and families stuck with huge bills after their “Ministry” refused to pay for care. Aliera Healthcare Inc. and Trinity Healthshares, Inc are the most visible example of what can happen without tight regulation. Regulators in multiple states issued cease and desist orders after concluding the companies violated laws; Aliera was found guilty of fraud and filed for bankruptcy late last year.

Tops among concerns is this – HCSMs are NOT required to have enough cash on hand to pay medical bills. Even more concerning, they don’t have to report their finances, cash reserves, expense ratios or other data.

There’s an effort underway to “accredit” HCSMs; the process/requirements don’t appear to address this critical issue and the accreditation board doesn’t include individuals with actuarial or financial credentials.

I’ve asked the lobbying outfit that purports to represent HCSMs for details on the financial portion of that accreditation process. So far they’ve been less than forthcoming.

What does this mean for you?

be very careful.